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Help-A-Pet Application and Agreement
Name and Age of Pet Owner:
 
Occupation or Type of Disability:
  
 

Address:  (street, apt., city, state, zip)
Phone Number with Area Code (Home):
(Cell):

Name, Address, & Phone Number of Veterinarian Clinic/Hospital or Medical Supplier:

Description of Diagnosis, Medical Treatment, Symptoms or Injury:
Estimated Cost of Treatment:  $
Amount You can Contribute: $

I,                                                                                                        , am the legal owner of

     (print name of pet owner)                         

                                                                                                                                                                      

(pet’s name, age, species – dog, cat, etc.)

I attest that the information I have provided to Help-A-Pet is accurate and complete.  I give my consent for the above-mentioned medical care.  I understand that Help-A-Pet assumes no liability and makes no assurances as to the appropriateness, quality or outcome of any medical diagnoses, treatments, products or services.  I consent to Help-A-Pet’s use of any pictures provided of my pet(s) or its owner(s) as well as a description of the medical care for purposes of promotion and fundraising.  I understand any documentation or pictures given to Help-A-Pet cannot be returned.
Signature: Date:

 

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